Every month, the Diagnosis column of The New York Times Magazine asks Well readers to solve a diagnostic riddle. Below you will find the details of a case involving a middle-aged woman on a Vermont camping trip who went to a rural emergency room with a range of odd symptoms. Notes and lab documents from the hospital can be viewed, as well as pictures of the terrible rash she developed. As usual, the first person to figure out the diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the pleasure of figuring out a case that stumped a bunch of very smart doctors.

The Presenting Problem:

A middle-aged woman on a camping trip develops a fever, rash and sore mouth and eyes.

The Patient’s Story

A 55-year-old woman was camping with her husband, her cousin and her cousin’s husband in the mountains of Vermont. They had arrived at the campground late in the evening, too late to really admire the beauty of the spot they’d picked. The next morning she awoke early — she was hoping for an early morning walk — but right away she knew she was sick.

She hadn’t brought a thermometer, but she knew she had a fever. Her whole body hurt. Her eyes burned and itched. Her gums were tender, and after she brushed her teeth the toothpaste was stained red with blood. Even urinating hurt; she felt as if there was a fire between her legs. Still, she assumed it was just a virus.

Her cousin’s husband was a doctor. When she told him she didn’t feel well, he looked into her eyes — they were red and looked irritated. Then he looked into her mouth. On her tongue and along the inside of her cheeks there were a couple of blisters filled with dark, almost black, liquid. Blood, he realized.

“You’re going to the hospital,” he announced. He didn’t know what this was — as a radiologist, he had never seen anything like it — but he was certain she needed medical treatment.

The closest hospital was over an hour away. It was the longest hour of the woman’s life. Every moment she felt worse. Her eyes swelled. Light began to hurt them. Her skin felt tender and itchy all over. Her head ached. And the motion of the car made everything just that much worse. She almost cried with relief when they finally reached the Brattleboro Memorial Hospital.

In the bathroom, the woman looked in the mirror. She could barely recognize herself. Her eyes were so swollen she could open them only a crack. Her face was puffy and blotched with red. Her neck and chest were covered with dark welts. She looked just as bad as she felt, she thought to herself.

The Emergency Room

The first couple of hours in the emergency room were a blur. Doctors, nurses and technicians zipped in and out, peppering her with questions, hooking up IVs, taking blood. By evening she was beginning to feel a little better. She’d gotten antihistamines for the itchy rash, and that had helped.

Finally, a middle-aged doctor introduced herself as Dr. Teresa Fitzharris. She was the E.R. doctor on the overnight shift. The patient began telling her story once more.

The latest symptoms had started only that morning, but the patient hadn’t really felt well for the past couple of weeks, since she and her husband had driven from their home in Connecticut to a different part of the state on a camping trip. During a hike on that trip, she’d gotten many black fly bites. It was awful. Every bite swelled up to make these enormous welts. It hadn’t hurt that much, but she thought she looked ridiculous.

The next week she’d traveled to see her niece. She recalled getting a terrible headache when she got home from that trip and had taken a couple of ibuprofen and gone to bed. The next day the headache was better, but she had a fever of 101 degrees. The fever lasted a couple of days, until just before this camping trip. The day before they were due to leave for Vermont, she’d been fine — no fever, no headache. Now the fever was back, and she felt as bad as she ever had.

The Doctor’s Exam

The patient had a fever of 101.6. Her heart was beating fast: 93 beats per minute. She certainly looked sick. Her face was flushed and swollen. Her eyelids were swollen nearly shut. The whites of her eyes — what little the doctor could see — were deeply bloodshot. The patient’s tongue and cheeks were covered with blood-filled blisters. Her trunk and neck were covered with deep red bumps that were somewhat tender to the touch. Dr. Fitzharris reviewed the labs that had already been sent by the doctor on the earlier shift. They were unremarkable.

Dr. Fitzharris wasn’t sure what was going on, but it was clear the patient wasn’t going to go home anytime soon.

You can read the emergency department note here:

You can read the radiology report here.

You can review the laboratory test results here.

Dr. Fitzharris called Dr. David Albright, the doctor on call that night, and told him about this patient, explaining she thought the woman was stable enough that he could wait to examine her in the morning. She reviewed the patient’s story, exam and labs, and together they discussed what should be done.

Early Treatment

Was this an infection? If so, was it viral or bacterial? Maybe it was neither. Could this be an allergic reaction? Dr. Fitzharris had called the infectious disease service at Dartmouth-Hitchcock Medical Center in nearby Lebanon, N.H. The fellow on duty suggested blood cultures and observation overnight.

Neither Dr. Fitzharris nor Dr. Albright was willing to just watch. After ordering the blood cultures, Dr. Fitzharris started the patient on antibiotics. She ordered ceftriaxone in case it was a run-of-the-mill bacterial infection, and doxycycline in case this was a tick-borne illness like Lyme disease or Rocky Mountain spotted fever. She also ordered antihistamines to reduce the itching.

You can read her note here.

Photographs of the patient’s rash, which were taken a week later, can be seen here.

Photo

The patient's rash extended across her chest and back.Credit

Solving the Mystery:

You now have all of the information that the doctor who made the diagnosis had. What do you think is happening to this previously healthy 55-year-old woman?

Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Reader comments may also appear in a coming issue of The New York Times Magazine.